Final Lee Taylor Manuscript

NATO-CSO-HFM-254 SYMPOSIUM
STO-HFM-254 8 - 1
Developing and Implementing a Technology Mediated Multidisciplinary
Healthcare Provider Program to Strengthen Care for Victims of Military
Sexual Assault
Lt Col. Wendy Lee, USAF, MSN, FNP-BC 1
Laurie Posey, EdD 2
Laura A. Taylor, PhD, RN, ANEF1
1Uniformed Services University of the Health Sciences
Daniel K. Inouye Graduate School of Nursing
4301 Jones Bridge Road, Bethesda, MD 22315
2 The George Washington University
2030 M Street, NW
Suite 300
Washington, DC 20036
UNITED STATES OF AMERICA
Wendy.lee@usuhs.edu, posey@gwu.edu, and Laura.taylor@usuhs.edu
The views expressed are those of the authors and do not reflect the official policy or position of the
USUHS, the Department of Defense, or the United States government.
ABSTRACT
Background: Sexual assault has a devastating effect on military personnel, service morale, and unit
effectiveness. Assessing and treating military sexual assault (MSA) presents significant challenges, but the
military medicine and nursing communities generally lack sexual assault education and training [2]. To close
this gap, the US Department of Defence and NATO have developed sexual assault policies. However, little is
known regarding the effectiveness of a pilot Military Sexual Assault Assessment and Treatment Program.
Objectives: To evaluate the effectiveness of the Military Sexual Assault Assessment and Treatment Program
(MSATP), a 16-week Uniformed ServicesUniversity of the Health Sciences pilot course that combines online
instruction, in-person panel discussions, and simulation events to educate advanced practice graduate
nursing and medical students across the uniformed services in the assessment and treatment of MSA.

COMPUTER-ASSISTED MEDICAL TRAINING
Developing and Implementing a Techonology Mediated Multidisciplinary Healthcare
Provider Program to Strengthen Care for Victims of Military Sexual Assault
STO-HFM-254 8 - 2
Methods: Thirty graduate nursing students completed the MSATP. Measures included pre and post surveys
measuring the knowledge, confidence, and communication skills necessary to effectively assess and treat
victims of sexual assault, aswell as satisfaction with the program’s content,organization, and effectiveness in
meeting target objectives.
Results: Significant increases were found in the confidence to assess and treat sexual assault victims.
Knowledge and interview skills were high at the end of training, but results regarding communication skills
and dispelling rape myths were mixed. Overall programsatisfaction scores were generally high, as were the
evaluations of the program’s content, organization, and effectiveness in meeting target objectives.
Conclusion: An evidenced-based programof online instruction, in-person panel discussions, and simulation
events can increase the knowledge, confidence,and skills needed to assess and treat victims of sexual assault.
1.0 INTRODUCTION
Protecting and safeguarding the health and well-being of military service members is critical for mission
security and unit effectiveness. However, assessing and treating military sexual assault (MSA) is challenging
and the rates of MSA are unacceptably high. Department of Defense Sexual Assault Prevention and Response
Office (DoD SAPRO) reports that as many as 6.1% of United States (US) active duty women (N = 13,054)
and 1.2% of US active duty men (N =10,080) are sexually assaulted each year [14], while the annual rape rate
across 17 North Atlantic Treaty Organization (NATO) may be as high as 92 per 100,000 [22]. Further, the
reported rates of MSA are increasing [8]. For these reasons, NATO has developed MSA policies [20] and the
US National Defense Authorization Act in 2014 mandated changes to the military law regarding MSA [18].
While these policy changes are designed to combat MSA, assessing and treating MSA remains challenging.
Education can improve confidence and instill the knowledge necessary to effectively conduct a sexual assault
assessment and to develop an appropriate treatment plan [6; 20, 26]. Classroom instruction can improve
student knowledge and confidence in caring for sexual assault victims [14, 17, 25]. Further, a combination of
classroom and online simulation can increase sexual assault assessment and treatment knowledge [24].
However, in the face of this empirical evidence demonstrating the efficacy of education and training in
assessing and treating sexual assault, training rates are declining.
Lack of training remains the primary barrier to assessing and treating MSA [6; 20, 26]. Nursing, medical, and
forensic professional education lags in the implementation of sexual assault education and training [2]. Worse,
training rates may be declining, as 2014 report from the Association of American Medical Colleges (AAMC)
found that only 38% of U.S. graduating physicians participated in victim care education, a 7% decrease from
the 2010 report [3].
To address this gap in education and training, the Deans of the School of Medicine (SOM) and Daniel K.
Inouye Graduate School of Nursing (DKI-GSN) at Uniformed Services University of the Health Sciences
(USUHS) mandated the development, implementation, and evaluation of a technology enhanced program on
military sexual assault (MSA) assessment and treatment. However, this 16-week Military Sexual Assault
Assessment and Treatment Program had not been evaluated. Therefore, what was needed was a study that
utilized a program evaluation approach to assess the efficacy of the Military Sexual Assault Assessment and

STO-HFM-254 8 - 3
Treatment Program (MSATP). The present study was specifically designed to fill this important gap in the
literature.
1.1 Purpose Statement
The purpose of this program evaluation study was to evaluate the Military Sexual Assault Assessment
and Treatment Program (MSATP) at USUHS.
2.0 METHODS
2.1 Participants
Participants were 30 graduate nursing students from the USUHS DKI-GSN who enrolled in the MSATP in the
Fall term of 2014 as a part of the established curriculum.
2.2 Ethical Considerations
This study was approved by the institutional review board (IRB) at USUHS and at The George Washington
University. Steps were taken to protect participant rights to privacy, anonymity, and confidentiality. Personal
identifiers were removed and replaced with codes prior to data analysis. Data were stored in a password-
protected drive and hard copies were secured in a locked cabinet in a secure private office. No compensation
was offered for participation and participant responses regarding program evaluation did not impact course
grading. The views expressed are those of the authors and do not reflect the official policy or position of the
USUHS, the Department of Defense, or the United States government.
2.3 Measurements
The study measuring instruments are summarized in Table 1.
The Sexual Assault Rape Myth Acceptance Assessment (SARMAA) measured the level of acceptance of rape
myths, which are the “prejudicial, stereotyped, or false beliefs about rape, rape victims, and rapist” [4, p. 217].
Of the sixty-one 1-to-5 Likert-type items (1 = strongly disagree, 5 = strongly agree), 31 SARMAA items were
included for analysis because they were related to MSATP course content. SARMAA has good reliability
(alpha = .74 to .87; 17; 20; 25). SARMAA took 15-20 minute to complete.
The New Jersey Medical School Sexual Assault Response Assessment (NJMS SARA) assessed knowledge
about the sexual assault assessment processes [23]. The NJMS SARA includes seven multiple-choice items,
with scoring expressed as overall percent correct. The NJMS SARA took less than five minutes to complete.
The Sexual Assault Interview Skills Assessment (SAISA) assessed the ability to ask appropriate questions
during a sexual assault interview [23]. SAISA includes 24 yes-no items, with scoring was expressed as
overall percent correct. SAISA took ten minutes to complete.
The Essential Elements of Communication (EEC) assessment assessed students’ ability to demonstrate
therapeutic communication [13]. The EEC scale is the sum of eight 1-to-5 Liker-type items (1 = poor, 5 =

STO-HFM-254 8 - 4
excellent) (range: 8-40), with low ratings indicating that communication skills need improvement [5]. The
EEC has high internal reliability (alpha = .94) and took ten minutes to complete [5].
The Unit Satisfaction Survey assessed satisfaction with the online program objectives, organization, and
introduction of new content, with three 1-to-5 Likert-type items (1 = strongly disagree, 5 = strongly agree).
This survey took less than five minutes to complete.
The USUHS DKI-GSN Program Performance Survey assessed program satisfaction across eleven 1-to-5
Likert-type items (1 = poor, 5 = excellent) and one overall course satisfaction item (1 = poor, 5 = excellent).
This survey took less than five minutes to complete.
2.4 Procedures: Online Program and Simulation Assessment Event
The MSA Assessment and Treatment program had two components. The first component used interactive
education, high-technology, and hands-on experiences throughout 7 online learning units (Table 2). Teaching
strategies included online instructional units, “photo journal” assignments, development of therapeutic plans
of care using evidenced-based treatment guidelines for victims and offenders, in-person panel discussions
involving an actual murder rape case involving a military offender, and demonstration of leadership skills in
multidisciplinary teams.
The second component of the MSA Assessment and Treatment Program culminated in a simulation
assessment event. Each student completed the NJMS SARA before participating in the simulation assessment
event. The simulation consisted of a two-hour rotation and began with a 30-minute session led by a Sexual
Assault Nurse Examiner (SANE). Students were familiarized with the DoD Sexual Assault Kit, and
procedures regarding the differences between restricted versus unrestricted reporting, and patient assessment
interview techniques.
Next, each student had a 45-minute encounter with a specially trained male or female standardized patient
(SP). SPs were guided on how to represent a sexually assaulted patient according to a faculty created
presentation which included history and physical symptoms for teaching, and assessment. Immediately
following the encounter, students self-assessed their interview and communication skills using the Sexual
Assault Interview Skills and Essential Elements of Communication Assessment [23]. SPs also completed the
Essential Elements of Communication Assessment following the student encounter. SPs privately also shared
their perceptions of the student interview with the student. The final segment of the event included a 30-
minute de-briefing session with a SANE, and a psychiatrist or physician experienced with caring for victims
of sexual assault.
Students were required to 1) complete all seven units of the on-line program, and 2) participate in a sexual
assault simulation and debriefing. In addition to knowledge and skill assessments associated with the sexual
assault simulation, students completed a variety of surveys related to satisfaction with the program instruction.
3.0 DATA ANALYSIS
Data were analyzed using ANOVA, t-tests, and non-parametric tests at the p < .05 threshold for statistical
significance.

STO-HFM-254 8 - 5
4.0 RESULTS
4.1 Results: Online Education Assessment
4.1.1 Unit Satisfaction and Program Performance Surveys
Unit Satisfaction Survey scores indicated that students, on average across seven instructional units,
“Agreed” regarding satisfaction with program expectations and effectiveness related to program objectives (M
= 3.9), organization (M = 3.9), and introduction of new content (M = 4.1) (Figure 1). The end of term
Program Performance Survey results indicated that students were generally satisfied with the course overall,
with “Agree” as the modal evaluative response across 11 course component items.
4.1.2 Sexual Assault Rape Myth Acceptance Assessment (SARMAA)
SARMAA results were mixed, with statistically significant (p < .05) improvements in 3 of the 31 items:
knowing what to do if a patient reported being raped, comfort level in listening to a rape history, and the belief
that most rapes happen to a woman alone at night. However, no statistically significant (p > .05)
improvements were found for the remaining 28 rape myths.
4.2 Results: Simulation Assessment Event
4.2.1 NJMS SARA Knowledge
NJMS SARA Knowledge scores increased from 81% correct (SD = 13%, Range= 57%-100%) to 85% correct
(SD = 12%, Range= 57%-100%) from Pre to Post simulation (Figure 2), but this improvement was not
statistically significant, t (27) = 1.53, p = .14. Overall, 64% of students scored above 80% correct Pre and 68%
scored above 80% Post (Table 3), but this improvement was not statistically significant by paired t-test (t (27)
= 0.37, p = .71) or by Wilcoxon Signed Ranks Test (z = 0.38, p = .71).
4.3.2 NJMS SARA Confidence
Confidence scores increased from 2.88 (SD = .86, Range= 1.20-4.40) to 3.68 (SD = .59, Range= 2.60-5.00)
from Pre to Post (Figure 3). This improvement was statistically significant, t (27) = 6.90, p < .0001.
4.3.3 Sexual Assault Interview Skills Assessment
Sexual Assault Interview Skills Assessment scores were significantly higher for students (M = 81%, SD = 8%,
Range= 63%-94%) than for SPs (M = 73%, SD = 12%, Range= 50%-94%) by paired t-test (t (29) = 2.94, p <
.01) and by Wilcoxon Signed Ranks Test (z = 2.61, p < .01). Overall, 63% of students self-scored above 80%
and 33% of SPs indicated scores above 80% on the Sexual Assault Interview Skills Assessment. This
difference was statistically significant by paired t-test (t (29) = 2.53, p < .02) and by Wilcoxon Signed Ranks
Test (z = 2.32, p < .02) (Table 3; Figure 4)
4.3.4 Essential Elements ofCommunication Assessment
Essential Elements of Communication Assessment scores were similar for SPs (M = 3.48, SD = .59, Range =
2.38-4.75) and for students (M = 3.26, SD = .59, Range = 2.00-4.33), roughly corresponding to “Good”. This
difference was not statistically significant by paired t-test (t (29) = 1.68, p = .10) or by Wilcoxon Signed
Ranks Test (z = 1.28, p = .20) (Table 3; Figure 5).

STO-HFM-254 8 - 6
5.0 DISCUSSION
Assessment and treatment of military sexual assault is challenging, but MSA education and training is
lacking [2]. To fill this gap, USUHS designed and delivered an evidenced-based technology-mediated
program that combined online instruction, in-person panel discussions, and simulation events to educate
advanced practice graduate nursing and medical students across the uniformed services in the assessment and
treatment of MSA
Overall, the goals of the pilot Military Sexual Assault Assessment and Treatment Program (MSATP) were
met. High satisfaction rating were given by MSATP students for meeting program objectives, program
organization, and introduction of new content. One student commented that “The opportunity to actually feel
that I was with a victim assisted in creating a reality experience. This greatly increased my knowledge about
how to engage a patient who has been the victim of sexual assault,” while another student remarked, “I now
have a stronger knowledge base that will put me at ease and allow me to talk to the patient and provide
information that will hopefully put them at ease as well.” Overall, the efficacy of the online phase of this study
was validated, but indicates the need for program improvement in specific areas, while the simulation phase of
MSATP was validated, but also points to the need for more repetitions with MSA scenarios.
NJMS SARA confidence scores significantly increased from pre-to post-simulation, consistent with Witt et al.
[26], who also found a significant increase in confidence scores regarding basic tasks associated with their
initial experiences with survivors of sexual assault. This suggests that the opportunity to apply new skills in a
simulated real-world setting can increase confidence.
NJMS SARA knowledge scores increased following the assessment event, though not significantly. The pre-
test scores were high (81% correct), consistent with prior studies of training using the NJMS SARA [14; 17;
25]. The high scores prior to simulation events may have been due to the scheduling of the program, as the
simulation event phase followed the online training, where significant learning opportunities were provided.
In contrast, findings from the Rape Myths Assessment Survey were mixed, with improvement evident on
three items (knowing what to do if a patient reported being raped,comfort level in listening to a rape history,
and the belief that most rapes happen to a woman alone at night) but not on other items. Future offerings of
the MSATP should increase the online rape myth assessment education content to further address rape myths.
Both student and SP scores on the Essential Elements of Communication Assessment were in the middle of
the 1-5 scale, roughly corresponding to “Good”. While acceptable, this highlights the need for further
communication skill building. Similarly, the Sexual Assault Interview Skill Assessment results were
acceptable, but also indicate room for further improvement. Additionally, the student-reported scores were
10% higher than standardized patient assessment scores, indicating that more can be done to build student
interview skills and self-assessment. Student written comments suggest that multiple iterations of simulation
assessment events would improve this component of their assessment. As one student commented, “I will
need continued practice with this type of interview.”

STO-HFM-254 8 - 7
6.0 IMPLICATIONS FOR PRACTICE
Present findings validate the efficacy of the MSATP, so NATO military medical service providers, company
commanders, and educational institutions should model and implement this evidence-based program or
similar programs to foster the effective assessment and treatment of victims of MSA. NATO or constituent
members should establish a database of evidence-based resources on MSA assessment and treatment for use
by company commanders, faculty and nurse leaders. Database resources that are modular and in a highly
accessible format will allow for expanded learning across NATO personnel without formal program
enrollment. Multiple iterations of simulation events are recommended to prepare healthcare providers with
training on a full range of MSA scenarios.
7.0 STUDY LIMITATIONS
This study was limited by the sample, which included only 30 US graduate nursing students, so results should
be generalized with caution. This study employed standardized measurement instruments that were previously
validated, but not specifically designed for the content delivered in this educational program. Therefore, the
measurement instruments utilized for this study may not have fully captured student learning. Ratings on
confidence, knowledge, sexual assault interview skills and essential communication skills have been shown to
improve with repeated exposures and simulation experiences [6; 20), but the present study was limited by only
including one simulation event. This pilot study was limited by the design, in that there was no long-term
follow up to determine the degree to which improvements due to training translate to effectively caring for
MSA victims of sexual assault when providers are deployed in military theater settings.
8.0 AREAS OF FUTURE RESEARCH
This study should be replicated with larger, more diverse samples from all NATO countries. Future research
should include the use of a control group, thereby serving as a comparison group to decrease experimental
bias in pretest-posttest measures. Future researches should strive to include on-point measures that are
specifically designed to align with program materials and trainings. Longitudinal studies are needed to explore
students’ application of program content to field practice when deployed.
Research regarding the incorporation of multiple iterations of the simulation assessment event with varied
content is recommended.
Program developers should explore fine-tuning the content and materials of the MSATP to ensure optimal
student outcomes. In particular, communication skills, interview skills, and rape myth knowledge can be
improved with improved course materials and procedures. Finally, it is critical that NATO leaders strive to
find effective methods to prevent MSA from occurring, thereby, fostering a safe environment for all NATO
service members.
9.0 CONCLUSION
The assessment and treatment of MSA is challenging, but this pilot study found that participation in the
Military Sexual Assault Assessment and Treatment Program (MSATP) at USUHS improved student

STO-HFM-254 8 - 8
knowledge, confidence, and communication skills in the care of MSA victims. Combined, present findings
highlight the importance of effective training to appropriately assess and treat victim of MSA.
Acknowledgements
Authors wish to thank Dr. Greg Zarow for statistical expertise and manuscript preparation. We also wish to
thank the Val G. Hemming Simulation Center for their dedication and coordination for a realistic multi-layer
simulation assessment event.

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Appendix A
Tables
Table 1: Tools and Instruments and Measurements
Tool Name (variable) and
variable definition
When Taken Number of items Type of Instrument Scale
Pre- Post-
Rape Myth Acceptance
Assessment
X X 31 Questions Likert Response Scale:
1- Strongly Disagree
2- Disagree
3- Neutral
4- Agree
5- Strongly Agree
New Jersey Medical School
Sexual Assault Response
Assessment
X X 7 Questions Question #1-7
Multiple Choice Single correct
questions
Sexual Assault Interview Skills
Assessment
X 24 Questions Questions #1-16-dichotomous response
scale: Yes or No answers
Essential Elements of
Communication Assessment
X 5 Questions Questions #17-24: Likert response
scale:
1- Poor
2- Fair
3- Good
4- Very Good
5- Excellent
Unit Satisfaction Surveys X 3 Questions Likert response scale:
1- Strongly Disagree
2- Disagree
3- Neutral
4-Agree
5- Strongly Agree
USUHS Graduate School of
Nursing Program Performance
Survey
X 1 Question #2: “My
overall evaluation of
the program.”
Likert response scale:
1- Poor
2- Fair
3- Satisfactory
4-Good
4- Excellent

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Table 2: Online course unit content
Unit title Readings PowerPoint
Presentations/Videos
Interviews Assignments
Introduction Medical Responseto Adult
Sexual Assault (Ledray,
Burgess, & Giardino, 2011)
Faculty introduction to
the course GSN
Dean Ada Sue Hinshaw
(2 min) SOM Dean
Arthur Kellerman (3
min) Dr. Patrick
DeLeon (Former
American Psychological
Association President) (2
min)
Pre course
Sexual
Assault Rape
Myth
Acceptance
Form
Unit 1: History,
culture, and
statistics of
military sexual
assault
Medical Responseto Adult
History of Sexual Assault
in the Military by Ann
Burgess(10 min)
Dr. Nathaniel Galbreath,
Senior Executive
Advisor on Research
Training of DoD Sexual
Assault (24 minutes)
Discussion
Board
Air Force AFI 44-102
Medical Care Management:
Chapter 16.5, Medical
Responsefor Sexual
Assault Victim
Military Sexual Assault
Survivor (5 min)
Unit Survey
BUMED 6310.11A CH-1:
Sexual Assault Prevention
and ResponseMedical-
Forensic Program
National Public Radio:
Off theBattlefield
Military Women Face
Risks from Male Troops
(7 min)
Unit 2: Sexual
Aggressors
Rape and Offender by Ann
Burgess
Rapist Types by Ann
Burgess (20 min)
Quiz
Interviewing the Rapist
(Hazelwood & Burgess,
2008)
Sexual Assault:A
survivor's story (9min)
Unit Survey
Interviewing the male
suspect created by Navy
Medicine (18 min)
Unit 3:
Interviewing the
Victim of a Sexual
Assault
Interactive multimedia
PowerPoint on
interviewing a suspect,
victim, and offender (60
min)
Discussion
Board

STO-HFM-254 8 - 14
Introduction about
Interviewing by Ann
Burgess
Reporting options created
by Navy Medicine (6 min)
Unit Survey
Behavioral Inverview of
the RapeVictim
2008)
Pre-exam conference and
forensic interview created
by Navy Medicine (8 min)
Interviewing the Rapist
2008)
Male rapeby M. Ortiz
(Navy SANE) (4 min)
Suggestions for a safe and
empowering gynecological
exam
Blue tubevideo on airman
imprisoned because of a
sexual assault offense
Military sexual trauma in
men: A review of reported
rates
DoD Form 2911
Documentation of the
medical/forensic
examination of the sexual
assault victim
Unit 4: Evidence
Collection and the
Sexual Assault
Forensic
Examination
Sexual Assault Forensic
Examination by CDR A.
Huber (Navy SANE) (14
min)
Quiz
Introduction to evidence
collection by Ann Burgess
Suspect Forensic
Examination by M. Ortiz
(Navy SANE) (18 min)
Unit Survey
Out of Range: Obstacles to
Reproductive and Sexual
Health Care in the Military
Sexual Assault Forensic
Examination (SAFE)
video created by Navy
Medicine (34 min)
Mentalhealth care for the
sexually assault victim by
Lt. F. Keith (Psychology
Resident) (26 min)
Maintaining evidence
chain of custody and
documentation by Navy
Medicine (4 min)

STO-HFM-254 8 - 15
Unit 5: Treatment
for Military Sexual
Assault Victims
Post-assault follow-up
plan for sexual assault
victims by Lt Col J
Korkosz (Womens Health
Nurse Practitioner)
Discussion
Board
Research studies on Sexual
Assault Treatment by Ann
Burgess
Referrals for follow-up
care created by Navy
Medicine (2 min)
Quiz
Barriers to care for sexual
assault survivors of
childbearing age: An
integrative review
(Korkosz, 2014)
You tubevideo 20
veteran's experience on
overcoming sexual trauma
(3 min)
Unit Survey
Unseen battles: The
recognition, assessment,
and treatment issues of men
with military sexual trauma
(Morris et al., 2014)
Case Study on US v Wilt
case by M. Ortiz (Navy
SANE) (5 min)
Unit 6: TheLegal
Process
Craigs list killer by the
Boston Crime lab (35
min)
Discussion
Board
Legal process by T.
Scalzo, Navy Esquire (23
min)
Unit Survey
Medical Expert Testimony
Trial (23 min)
Panel discussion on
military rape and murder
case (60 min)
Unit 7: Prevention
and advances in
forensics, research,
and policy in
military sexual
assault
Research and Policy on
sexual Assault by Ann
Burgess (13 min)
Concept
Journey map
You tubevideo on The
Daily Show: The fault in
our schools (5 min)
Unit Survey
Post-Course
Sexual
Assault Rape
Myth
Acceptance
Form

STO-HFM-254 8 - 16
Table 3: Sexual Assault Interview Skills Assessment and Essential Elements of Communication
Assessment Descriptives for SPs and Student
Assessment Communication
Statistic SP Student SP Student
Mean 73% 81% 3.49 3.26
N 30 30 30 30
SD 12% 8% 0.59 0.59
>80% Rating 33% 63%

STO-HFM-254 8 - 17
Appendix B
Figures
Figure 1. Unit Survey summary, averaged across 7 instructional unit
Note: Error bars reflect standard error of the mean (SEM).

STO-HFM-254 8 - 18
Figure 2. NJMS SARA Knowledge, student self-reported pre and post training.

STO-HFM-254 8 - 19
Figure 3. NJMS SARA Confidence, student self-reported pre and post training.

STO-HFM-254 8 - 20
Figure 4. Sexual Assault Interview Skills Assessment by standardized patient and students.

STO-HFM-254 8 - 21
Figure 5. Essential Elements of Communication Assessment by standardized patient and students.

Final Lee Taylor Manuscript

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